Basic Information
| Provider Information | |||||||||
| NPI: | 1700888997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9001 SUMMA AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257615200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9001 SUMMA AVE | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708093726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257615200 | ||||||||
| FaxNumber: | 2257615538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 021620 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD021620 | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 1660400 | 05 | LA | MEDICAID | 00124748 | 05 | MS | MEDICAID | 00588343 | 05 | MS | MEDICAID |